An earlier version of this story incorrectly conveyed a medical term.

PITTSFIELD — Four students wearing nursing uniforms huddled around textbooks, calculating proper doses of saline, antibiotics and Dilaudid. They washed their hands and headed into the hospital room.

The patient might be a mannequin, but her eyes blinked behind oval-rimmed glasses and her chest heaved with breath.

"I've been coughing, and it's making my belly hurt," Mary the mannequin said.

A bedside monitor beeped as Kelsey Lane used a stethoscope to listen to Mary's lungs.

"My belly really hurts and my dressing feels wet," Mary said.

The nursing program at Berkshire Community College graduates about 50 nurses a year into the local economy, and Berkshire health care employers already struggling with vacancies say they don't know how they'd fill nursing positions without it.

But recent regulatory hurdles put that pipeline in jeopardy.

The national accreditation agency ACEN and the state regulatory authority, the Massachusetts Board of Registration in Nursing, launched separate reviews of BCC's nursing program in the past year. Both agencies are calling on the college to keep better records and prove through data that its nursing students are achieving the required skills.

"It's a lifeline for us, because that's how we stay open," said George Mercier, administrator of Mount Carmel Care Center. "If you're in the business of health care, you view the development of your licensed staff as your lifeblood."

Mercier stressed the need for BCC to clear these regulatory hurdles quickly, in order to restore quick confidence in the crucial employment pipeline.

Graduates of the college's two-year nursing program receive associate degrees in nursing, and become registered nurses upon passing their National Council Licensure Examination. Students can also take a one-year path and become licensed practical nurses.

After a visit in October, representatives of ACEN said the program wasn't ready to be upgraded to a full accreditation status. The agency remains concerned about student outcomes — an accreditation standard that requires an educational facility to maintain certain test scores and keep records and data to prove students are achieving national benchmarks.

The recent review followed a decline in student scores on the NCLEX exam. Last year's rate dipped to 74 percent, lagging behind 80 percent benchmarks, and if the pass rate doesn't reach 80 percent in the spring, it constitutes a violation of state regulations.

On the national side, Marsal Stoll, CEO of ACEN, said the organization will gather more information about BCC's nursing program in February before making an accreditation decision in March.

She said the program is on an upward trajectory when it comes to resolving outstanding issues.

"However, there's still some things in progress and the work isn't finished," she said. "And with a little bit more time, they can finish the job."

Decision on the horizon

In March, the national board could decide to deny the Pittsfield program's accreditation outright, to extend its conditional status for another year or upgrade its status to full accreditation if it finds no further issues.

We'll just have to be patient and wait and see," Stoll said. "This is a very thoughtful, deliberative process that takes time."

In the worst-case scenario, nursing students can still sit for board exams and become registered nurses if the program loses accreditation in the spring, said Jennifer Berne, the college's vice president for academic affairs.

Berne said the program needs to be better about keeping data on student outcomes.

"We're satisfied students are getting the education they need," Berne said, but regulations say that's not enough. She said the program needs to be able to explicitly show, with data, that students are graduating with the proper skill set.

Both the national accreditation agency, ACEN, and the state regulatory authority, the Massachusetts Board of Registration in Nursing, are calling on the program to implement a systemic student evaluation program that proves students are graduating with the same level of nursing knowledge as others across the country.

"It's good for us to call very careful attention to that," Berne said.

In July, the state board told college leaders they have until Jan. 31 to implement a data-driven evaluation plan for the program.

Recruitment `a full-time effort'

Berne said faculty turnover placed strain on the program in recent years — the college recently turned over all four positions in its LPN program, and two out of five positions in the associate's degree in nursing program.

Outgoing faculty, including "quite a few retirements," took institutional wisdom away with them. Retirements are a regular challenge, Berne said, because many nursing educators don't get into teaching until late in their nursing careers.

"Often, nurses have been nurses for 20 years when they come to us," she said.

The goal, Berne said, is to apply new procedures that transcend any people around it. Job retention in nursing education is tough everywhere, Berne said, and there are unique job-recruitment challenges facing the Berkshires.

Christine Martin came out of retirement in October in order to fill the program director position after the resignation of the program's previous chief, Tochi Ubani. Berne said Martin is committed to stay while the college seeks a permanent replacement.

The leadership position creates a special challenge, she said, as one must have significant qualifications to pass muster.

"We're trying to deepen our pools," she said of the search.

She hired a consultant last month to support the planning process ahead, she said, and is busily helping the staff juggle corrective action and the work of educating students.

College leaders had to ask nursing program staff to work more over the holidays than they usually would, she said, in order to meet looming regulatory deadlines in January and February. In response, she said, "they've been extremely generous with their time."

"We all have a great desire to do this right," she said. "We don't want to just comply. We want to get better."

Employers are feeling the recruitment crunch, too, they said.

Among the county's nursing homes, about one in every five licensed nursing positions in the county are vacant, according to the Massachusetts Senior Care Association. That compares with a one-in-seven vacancy rate statewide — a discrepancy that makes the Berkshire rates so high they're "astounding," said Kate Kahn, a spokeswoman for the association.

Mercier said he and his team spend a significant amount of time already recruiting staff, and without the ability to incentivize his staff to get degrees through BCC the employment puzzle could become "untenable."

He said the regulatory issues at BCC are troubling for him as an employer.

Some would-be nurses are already hesitating to apply for the program, he said, because of what they perceive as its vulnerable status.

"They want to know they're investing on solid ground," he said.

There is high demand for nurses around the country, leaders of Berkshire Health Systems said, and their organization is no different.

Systemwide, BHS employs 643 nurses. Currently, the health care organization has 42 open RN positions. Patrick Borek, vice president for human resources, said it takes an average of 43 days to fill a nursing position.

"Finding high-quality RNs is always a challenge," he said, calling it "a full-time effort."

Brenda Cadorette, chief nursing officer for Berkshire Health Systems, said 50 to 60 percent of the nurses hired each year came through the nursing program at BCC.

The community college program also feeds the hospital system's in-house bachelor's degree program, which launched through a partnership with Elms College in 2007.

"BCC is critical in our ability to staff the organization, linking residents to health careers," said Michael Leary, a spokesman for BHS.

According to statewide labor stats, there are 2,136 unemployed Berkshire County residents actively seeking work, said Heather Boulger, director of the Berkshire Regional Employment Board. Meantime, there are 222 health care positions posted right now on local job sites.

Nearly 100 of those available jobs are nursing positions, and nearly all of those are either registered nursing positions or LPNs.

Health care and social systems is the largest employment sector in the county, she said, as the industry employs 12,800 people countywide.

"There's definitely a strong need for the nursing program at the college," Boulger said, calling it "one of our most important training programs" in the Berkshires.

Mary the mannequin

In the classroom Wednesday, students practiced their newfound skills on Mary the mannequin.

Professors sat on the other side of a two-way mirror, feeding Mary's lines and observing the students.

After their plastic patient repeatedly complains about abdominal pain, the students check her surgical wound and find exposed bowels.

"What's going on?" Mary kept asking.

"Paging Dr. Pepper," the students said, as a blur of blood and bandages took hold of the room.

Associate Professor Joanne Heaton, aka "Dr. Pepper," picked up the page.

"Cover the wound with saline; keep it moist," she told them. "Just get her prepped for surgery."

Heaton smiled as the students worked to insert a catheter.

"They spent the whole semester learning these skills that are now coming together," she said.

Back in the classroom, professors and students watched a video recording of the situation the students just enacted. Students asked their professor how best to handle questions from patients who want to know what's going on.

Sue Smith, an adjunct professor, said it's best to leave the details to the doctor.

"Say `your wound looks different. We need the doctor to come up and look at it,' " Smith said.

It's not your place as a nurse to say whether the patient is heading to the operating room, she said, but "in your mind, you're saying OR."

Lane pointed out that the patient was becoming more hypotensive.

"Why do you think she was doing that?" Smith asked.

"Because she was bleeding," Lane said, to a nod from Smith.

Smith and Heaton instructed students to ask more questions when a patient complains of pain. Ask them where it hurts, they told them. Ask them to describe it and ask if the pain has changed.

The college's Hawthorne building, completed in 2015, has a full imitation hospital wing full of mannequins. Similar to Mary, there's also a "simulator mom" that helps students learn how to deliver babies.

Students said the simulation was helpful and they looked forward to more.

"The more of this we have, the more calm and collected we can be," Lane said.

Amanda Drane can be contacted at, @amandadrane on Twitter, and 413-496-6296.